August 10, 2012
Volume 56, Issue 32
WHA to Lead, Participate in November 29 AHA DC Fly-In
The fight against proposed hospital payment cuts continues with the American Hospital Association (AHA) announcement of three Washington, DC Capitol Hill fly-in dates during the remainder of 2012. Fly-ins are scheduled September 11, November 29 and December 11. The Wisconsin Hospital Association plans to focus efforts around the November 29 date, including scheduling and staffing Hill visits.
"With so much at stake later this year and into 2013, hospital representation in Washington, DC will be extremely important," said WHA President Steve Brenton. "It provides us another opportunity to remind Congress about the high-value health care Wisconsin hospitals provide and how arbitrary fiscal cuts work to diminish that value for everyone."
Details on the AHA trips can be found at: www.wha.org/education/advday12flyer.pdf.
If you would like to participate in the November 29 Washington, DC fly-in (or any of the other AHA fly-in dates), please contact Jenny Boese, vice president, external relations & member advocacy, at email@example.com or 608-268-1816.
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Described as one of the most knowledgeable members of the Wisconsin Legislature on health care issues and a past Department of Health Services Secretary, Senator Tim Cullen (D-Janesville) told members of the WHA Public Policy Council that he favors the creation of a Wisconsin-run health care exchange.
"The discussion of exchanges got tangled up in politics," according to Cullen. "But, I like the idea of being able to compare networks and providers. With an exchange, we could finally have informed consumers, and only when they are informed will we be able to make progress on health care costs."
Cullen said Wisconsin hospitals are "way out ahead" in publicly reporting quality and price information. He said he’d like to see a web-based exchange developed that has links to the existing information that WHA makes available on WiCheckPoint.org and WiPricePoint.org, along with more outcome and performance data.
"Everyone talks about cutting health care costs, but cutting Medicare reimbursement doesn’t reduce health care costs," Cullen said. "People can reduce health care costs."
Cullen said he is hopeful that the Wisconsin Legislature will discuss health exchanges through the rest of the summer and into the fall. He believes that the political temperature is falling, and the state is "calming down" politically.
"People want legislators to work together and work things out," Cullen said.
Supreme Court Decision on Health Care Reform: What Does it Mean for Wisconsin?
Joanne Alig, senior vice president for policy and research at WHA, walked the Council through WHA’s current analysis of the Supreme Court decision on the Patient Protection and Affordable Care Act (ACA). Although WHA staff has taken a comprehensive look at Medicaid, there are a lot of moving parts at the federal level, and the analysis will continue to evolve as issues continue to emerge.
Alig touched briefly on the upholding of the individual mandate under Congress’s taxing authority and indicated WHA continues to analyze the impacts of all aspects of the coverage mandate, including subsidies and taxes for individuals and businesses. In addition, because the Supreme Court upheld other provisions of the health care reform law, including the requirement that all states implement a health insurance exchange by 2014, Alig noted that time is short for deciding on a state-run exchange. While up to 17 states have enacted legislation or executive orders to implement exchanges, Wisconsin has not, and the Walker Administration has indicated a decision will not be forthcoming until after the November elections.
Despite upholding most of the health care reform law, the Supreme Court’s key ruling was on Medicaid expansion. All seem to agree that the ruling makes optional the ACA’s requirement to expand eligibility to anyone with income below 133 percent of the federal poverty level. In Wisconsin the key population group that would be affected by this provision is adults without dependent children (the "childless adults").
According to Alig, key questions include the level of federal matching funds available to Wisconsin for the childless adult population; the scope of the Medicaid expansion and whether the ruling applies to other policies such as the maintenance of effort requirement; and even whether subsidies are available to purchase coverage in a federally-run exchange.
Alig said it ultimately boils down to policy questions about what income threshold should be used to determine eligibility for Medicaid for all population groups and whether subsidized coverage through an exchange is a better alternative. The answers to these questions require careful consideration of the impact on recipients and on the uninsured, the impact on provider reimbursement and the cost-shift, and the impact on the state budget for Medicaid.
The discussion also covered the expected reduction in disproportionate share hospital (DSH) funding under the ACA. The ACA includes a reduction in DSH as a result of expected coverage expansions. The federal Secretary of Health and Human Services (HHS) has authority to determine the methodology for that reduction, but it has to be based on a state’s level of uninsured. No one knows yet how HHS will rule and whether states that refuse to go along with the Medicaid coverage expansion will see a bigger or lesser reduction in DSH funding compared to other states.
As next steps, WHA will reconvene the Medicaid Reengineering Group (MRG). The MRG was created last year to develop policy recommendations around Medicaid reforms. The MRG created 47 recommendations in a variety of areas including care coordination, pay-for-performance, eligibility and enrollment and benefit redesign. The MRG will meet soon to discuss the options facing the state, and develop specific recommendations as policymakers grapple with choices for the Medicaid program.
Council Discusses Advocacy Campaigns, Emerging Issues
While legislators in Madison may be largely focusing on campaigns and the election season, issue activity at WHA during the summer interim period between legislative sessions remains at a high level. WHA staff provided Council members with updates on two key advocacy campaigns and discussed some issues emerging for the 2013-14 session.
WHA Executive Vice President Eric Borgerding said the months-long advocacy campaign focusing on High Quality, High Value Health Care: A Wisconsin Advantage is hitting high gear, with full page ads appearing in newspapers around the state. Additional advocacy pieces that focus on hospitals are also nearing completion, including an anchor piece highlighting Wisconsin’s recent No. 2 national ranking in health care quality by the federal Agency for Healthcare Research and Quality (AHRQ), and detailing the state’s high performance on such measures as affordability and access, choice of setting and provider, and quality of life and care, among other measures.
The ads and additional material will be used in conjunction with editorial board visits, meetings with top chambers of commerce, op-eds, guest columns and briefings with key policy-makers to tout the quality and value of health care in Wisconsin. Led by our hospitals, high health care quality and value here factor directly into labor costs and improving Wisconsin’s competitive edge in expanding economic development.
"Our efforts will be focused on encouraging businesses to engage in conversations with their local hospitals on ways they can work together to improve the business climate," Borgerding said.
Borgerding also updated Council members on the "Protect Hospitals" campaign taking place at the federal level. With the so-called end-of-year "fiscal cliff" fast approaching—including extension of the debt ceiling, the SGR physician payment fix, and sequester cuts amounting to hundreds of billions of dollars in across-the-board cuts to health care and other domestic and military spending—WHA and our member hospitals are hard at work in Washington addressing deficit reduction.
"Protect Hospital Care," WHA’s multi-pronged advocacy campaign against federal payment cuts, is running from 2012 until Congress acts. It includes dozens of strategies to ensure key stakeholders and decision and policy-makers are educated on the issues and the impact federal payment cuts will have on hospitals. White papers, issue papers, background information, links to AHA resources and WHA grassroots tools can all be found at the micro-advocacy site: www.wha.org/protecthospitalcare.aspx.
Multiple AHA Washington Fly-Ins are being planned, including one that WHA is focusing on, scheduled November 29. Others are set September 11 and December 11. Also included as part of the effort are telephone town halls with Wisconsin’s Congressional delegation, like the one recently completed with Congressman Ron Kind (D-La Crosse) Borgerding said. A call with Congressman Paul Ryan (R-Janesville) is scheduled September 7, and a listening session with Congressman Reid Ribble (R-Green Bay) is set August 22 in Green Bay. Both events provide the opportunity for direct dialogue between WHA members and members of Congress on these important issues.
Laura Leitch, WHA senior vice president and general counsel, and Judy Warmuth, vice president workforce, updated Council members on several issues emerging for the 2013-14 legislative session.
A joint WHA Wisconsin Medical Society workgroup continues to discuss how to best address the recent Wisconsin Supreme Court split decision in the Jandre case. The decision left physicians without clear and workable direction from the Court on a physician’s responsibility to inform patients about treatment or procedures the physician is not recommending. There is significant concern that this decision will lead to "defensive medicine" by physicians and an increase in the number of unnecessary screenings and diagnostic tests, but also will impede efforts to move from away volume-based and toward value-based health care delivery.
WHA continues to work with Wisconsin Manufacturers and Commerce (WMC) on a human resources policy work group aimed at streamlining a number of state laws that affect workforce development in the state. Differing regulations at the state and federal level are confusing and costly to decipher and create an unnecessary regulatory burden in Wisconsin.
Leitch and Warmuth updated Council members on two rules being worked on by the Medical Examining Board (MEB). Med 8, relating to Physician Assistant (PA) supervision has raised questions about the difference between a physician’s clinical and administrative supervision of PAs. Med 10 is the overall rule regarding physician misconduct. WHA continues to follow both rules closely and is actively participating in the rule-making process.
WHA Vice President of Government Affairs Paul Merline updated Council members on WHA’s candidate education efforts. As in prior election seasons, WHA is visiting key districts to inform legislators and candidates about priority issues for hospitals in the next legislative session. To date, over two dozen meetings have been held around the state, with visits continuing up to and beyond the November elections.
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Despite the delay, ICD-10 conversion looms on the horizon. Donna Smith, project manager for 3M, presenting at the August 8 WHA Finance Council, described what hospitals can do to determine the financial effect ICD-10 will have on reimbursement.
"Modeling financial impacts can highlight product line and DRG areas with significant variances in payment due to the conversion. This information can help guide providers as they develop and target their training and education for coders and physicians," according to Smith.
Debbie Rickelman, senior director of the WHA Information Center, discussed how WHA and the WHA Information Center are investigating ways to help hospitals analyze this impact. She also reminded the Council that WHA and the WICD-10 workgroup continue to meet and make available resources on the wicd10.org website to help providers as they continue their preparations for ICD-10.
Turning to the topic of health care reform, Joanne Alig, senior vice president for policy and research at WHA, discussed with Council members WHA’s current analysis of the Supreme Court Decision on the Patient Protection and Affordable Care Act (ACA). Alig briefly discussed the individual mandate and insurance exchange provisions of the ACA, but highlighted the impacts of the Medicaid expansion provisions. Alig noted that policymakers will likely be considering the financial implications of providing Medicaid coverage for various population groups, compared to subsidized coverage through health insurance exchanges. Ultimately, decisions will include consideration of the impact on recipients and providers, as well as the state.
Kevin Boren, CFO of Meriter Health Services, shared Meriter’s experience in the Partnership for Healthcare Payment Reform Total Knee Replacement Pilot. He gave three reasons for participating: to prepare for the future of health care and payment reform; to focus on reducing cost and improving quality in a discreet unit; and, to learn from others in the group.
"The impact of the project so far is that it has positively impacted team building and communication, it has created a greater appreciation of the patient experience across the episode of care, and it has allowed us to develop the ability to pull data to track costs across the phases of care," said Boren. Since participating in this pilot, Meriter has also applied for a CMMI Medicare bundled payment project.
In other Council business, Jenny Boese, vice president of external relations and member advocacy, provided an update on federal issues that are in play and the Protect Hospital Care campaign to help WHA members as they communicate with their legislators.
Finally, Brian Potter, WHA senior vice president, finance, updated the Council on several Medicaid issues including the 2013 hospital assessment, and the development of an enhanced ambulatory patient groupings (EAPG) outpatient payment methodology that is scheduled to go into effect January 1, 2013.
Potter also discussed an upcoming CMS hospital outpatient payment panel meeting that will focus on physician supervision. Jim Nelson, CFO at Fort Healthcare and Council member is on the panel and Dr. Mark Thompson, chief medical officer from Monroe Clinic, is testifying. Potter also announced that John Russell, CEO at Columbus Community Hospital and Council member was now on the Health Insurance Risk-Sharing Plan (HIRSP) board.
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If you are on Medicaid and looking for a doctor, the chance you’ll find one is excellent…in Wisconsin… and Minnesota…and Iowa.
But in New Jersey, California, Illinois and Florida…not so good.
Less than 70 percent of the nation’s office-based physicians will see new Medicaid patients, according to the health affairs study (reported in the Kaiser Health News this week). That number compares to 80 percent for Medicare patients.
Why? Low pay. Not surprising, given that Medicaid is consistently an embarrassingly bad payer across the country.
But in Wisconsin and Minnesota, where physicians are largely employed by hospitals or large group practices, the percentages are 93 percent and 96 percent—and that’s not because of competitive payment. The employment model likely drives the higher percentages, along with the fact that medicine continues to be viewed as a community-based asset in the upper Midwest.
But in New Jersey (40 percent), California (57 percent), Illinois (65 percent) and Florida (59 percent), access for Medicaid patients is a difficult struggle. Imagine what it will be like in 17 months when millions of newly-covered low-income patients try to find a doctor.
PPACA boosts Medicaid payment next year for primary care docs by about 30 percent in order to encourage participation in Medicaid. But that spigot runs dry in 2014, and the likelihood that Congress, unable to "fix" the chronically-broken SGR, will find funds after that is highly suspect.
It isn’t just poor payment that is creating this access problem. Even with inevitable scope of practice changes that will move advanced practitioners into primary care roles, there won’t be enough primary care physicians. And the escalating movement toward more population-focused health delivery will be starved for primary care physicians. Supply is an issue that won’t fix itself soon.
This topic must be top of mind as we move forward. When Congress looks to either "improve" the ACA next year—or repeal and replace OBAMACARE—A large investment in graduate medical education with a primary care emphasis must be at the top of the priority list.
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Sen. Julie Lassa (D-Stevens Point) met with CEO Philip Stuart at Tomah Memorial Hospital August 2. The visit and hospital tour was the first for Sen. Lassa. Redistricting has put northern Monroe County, including Tomah, into the Senator’s 24th district.
"I think we need to make sure that the end goal is that people are getting the high quality health care that they need at an affordable price," Lassa said following a discussion on the Supreme Court’s decision on the Patient Protection and Affordable Care Act (PPACA) and the impact on Wisconsin.
"The health insurance exchange really is a way for consumers to be able to make the best decision for themselves and what they can afford," Lassa added.
Discussion also focused on the value of independent community hospitals and their importance to local economic development, along with Medicaid reimbursement, plus education and the impact licensing and regulations create for staffing key hospital employees.
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Hospital and health care marketing and public relations professionals should plan to attend the 2012 Wisconsin Healthcare Public Relations and Marketing Society (WHPRMS) annual conference, October 3-5 at The Osthoff Resort in Elkhart Lake. This year’s event will include networking opportunities with peers and leaders in health care marketing, the opportunity to share best practices via interactive roundtable discussions, and the ability to learn about some of the hot marketing trends and topics.
The conference will feature keynote speaker Gary Mueller, executive vice president and creative director for BVK and founder of Serve Marketing, the nation’s only all-volunteer, non-profit ad agency. Mueller will focus on how highly-targeted, frequently-changing micro campaigns are changing the way brands market themselves.
Additional conference topics will include: conducting a communications audit, mobile access as part of your marketing mix, collaboration between physician relations and marketing, fundamentals of CRM and marketing strategies for small hospitals.
The conference will wrap Friday morning with a session focused on four radical ideas for marketing success from Chris Bevolo, author of "Joe Public Doesn’t Care About Your Hospital," followed by a reactor panel of WHPRMS members moderated by Bevolo.
The full conference brochure, with registration information, is included in this week’s packet. Registration is available online at http://events.SignUp4.com/12WHPRMS, and an early bird discount is available for those registered by August 31.
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With a focus on direct care-giving staff, Wisconsin’s Transforming Care at the Bedside (TCAB) project aims to improve patient care, improve team vitality and teach improvement techniques. Fifteen hospitals and 17 nursing units are involved in the current project, which is nearing completion after 18 months of activity. WHA’s Judy Warmuth has conducted a second round of site visits to the participating medical-surgical nursing units to hear their reports and to see the progress made by these teams.
An energetic Portage TCAB team reported on implemented projects and new plans and ideas. Phones for CNAs and notations for needed supplies have been implemented. Changes to dietary delivery time and grab-and-go baskets have created improvements. The group has also created a process for staff-to-staff recognition for work well done.
Two nursing units at Meriter participated in TCAB and both conducted their site visits as rounds on their units. Improvements in HCHAPS scores on both units have encouraged the teams. Strategies such as provider information at the head of the bed, comfort plans (as opposed to pain management plans) on the patient white boards, implementation of ‘no passing zones’ and management of telemetry units were presented. Improvements done at the beginning of the project have stuck. The two units have worked independently on issues but have also learned from each other.
Health care is a constantly changing environment, and like other TCAB teams, Osceola has worked with census and staffing changes. Despite the complex environment, team vitality scores have improved, and data has been successfully used to improve patient outcomes. The team shared their innovations grid and plans for sustaining the staff involvement and interest.
These are the final visit reports. The project will be completed in September, and hospitals have been asked to identify how they will ensure that the learning, energy and improvement activities continue after that date. A second group of hospitals will be invited to join the TCAB program this fall.
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Marriott Hotel, Madison
Make your hotel reservations before the deadline of August 31
Brochure and registration information can be found online athttp://events.SignUp4.com/12LeadershipSummit0921
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Member News: Delfs Named CEO of Richland Hospital
Mike Delfs has joined the Richland Hospital team as the new chief executive officer. Delfs brings more than two decades of experience in health care management along with strong expertise in growing and expanding health care services. He most recently served as the chief operating officer at Riverwood Healthcare in Aitkin, Minnesota.
Delfs holds an MBA from the University of Mary in Bismarck, ND with a focus on health care. He is a fellow with the American College of Healthcare Executives.
"I am very impressed with the team at the Richland Hospital as well as the Richland Medical Center and everything that has been accomplished here," Delfs said. "I look forward to being part of that team and helping to develop the health care services in our area even further."
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Fear of a bill should never prevent a patient from seeking care at a Wisconsin hospital. Wisconsin hospital charity care programs provided $232 million to more than 700 patients each day last year. The stories that follow illustrate the deep commitment and continuing concern that hospitals have to their patients to ensure they receive the care they need regardless of their ability to pay.
Charity cataract surgery helps daycare worker "see" the future
Although child care workers are in great demand due to the number of young mothers now in the workforce, they are still one of the lowest paid professions with a mean annual income of just $21,000 nationally. With these low wages and typically no health insurance coverage, these daycare workers are likely candidates for charity care. According to the recent census statistics, that’s more than 1 million workers who may be self-employed or have little access to health insurance.
This is the situation for Kathie H., of Beloit, who discovered the difficulty of getting quality health care with no insurance. At the age of 52, widowed, and working at a large daycare facility for the past 12 years, Kathie is facing some major health care challenges. Her vision is quickly deteriorating due to two dense cataracts in her eyes. Her vision is so impaired that Kathie says vision in her right eye looks like a large white snowball.
Thanks to her caring ophthalmologist, Dr. Alice Townshend, and Beloit Health System, Kathie will have both of her cataracts removed in the upcoming weeks, and her restored vision will keep her working and active. Dr. Townshend went to bat for Kathie and submitted her name to qualify for charity care. Thanks to her generous offer to donate her surgical services and the hospital’s willingness to write-off her surgical charges, Kathie will receive her new "eyes" for free.
"I am so excited about correcting my vision," explains Kathie. "For me to keep my job, I need to read, complete paperwork, and have reasonable vision. Right now, I am having real difficulty."
Kathie has been very motivated to improve her health and in the last year has dropped 130 pounds by eating sensibly. Now with the prospect of better eyesight, she "sees" a much brighter future.
Beloit Health System
At Mayo Clinic Health System - Franciscan Healthcare, assisting patients with the charges associated with their care is an expression of our Franciscan tradition of respecting the dignity of all people and believing that everyone deserves the same level of care regardless of their status. Challenging economic times continue for many patients, and unanticipated circumstances can arise for anyone at any time. Our experience is that assistance provided to patients is more important than ever and that the need is as great as ever. As patients apply for assistance, we see a growing population in our community where their inability to pay is brought on by forces outside their control.
"…I was embarrassed and angry. Now I am grateful and hopeful." Words from an unemployed cancer patient – a few years too young for Medicare – when she received news that her debt of more than $3,000 was excused as part of the Patient Financial Assistance (charity care) Program.
Financial challenges also arise among young people who no longer qualify as dependents for their parent’s insurance coverage. A full-time nursing student who did not qualify for her parent’s plan could not pay for her observation stay. Her charges of more than $6,000 were excused. As part of her expressing thanks to us, she noted that she passed her RN board examinations and was looking forward to a career in health care.
A local couple had no insurance and also faced expenses related to the death of their son. $21,000 of her emergency surgery charges were excused through the Patient Financial Assistance Program. "Your mercy towards us…has reassured us that prayers are still answered."
"Your generosity…has given me a new beginning at life," said a young, unemployed man who had more than $11,000 in addiction treatment charges excused. "During my stay I was treated with respect – although I did not deserve it at the time. Thanks to you the one thing I have now is hope."
A young person visiting the area needed emergency surgery. It was the summer between their senior year in college and entering law school. With no insurance and facing more than $11,000 in charges, additional years of school looked doubtful. "Your assistance…allowed me to start school without this significant burden. Thank you."
During 2010 Mayo Clinic Health System – Franciscan Healthcare has provided financial assistance to more than 775 families.
Mayo Clinic Health System - Franciscan Healthcare, La Crosse
An unforgettable journey to recover, a diploma, and a job
A college student in his mid 20s was covered in a pool of blood on the basketball court. As a crowd of his teammates huddled by his side, his mother frantically made her way down the bleachers to be with her son. He was rushed to the Emergency Department at Aurora St. Luke’s Medical Center. Blood continued to gush from a severed vein in his lower leg. Upon diagnosis, experienced surgeons performed emergency vascular surgery to seal the wound.
At the time, the patient was a college student studying at Milwaukee Area Technical College (MATC) to become welder. As are many college students, he was unemployed, uninsured and lived with his mother, Karen, who was extremely worried about the hospital bill. She contacted Financial Counselor Jeanne Witkowski to discuss her financial status and payment options.
"Jeanne explained the Aurora Helping Hand Patient Financial Assistance Program and assured me she would help. She was caring and kind. She followed up with me right away," said Karen.
Her son’s journey to recovery required several follow-up surgeries and physical therapy. Karen was grateful and relieved to learn that her son qualified for a 100 percent discount through the Aurora Helping Hand Patient Financial Assistance Program for the medical care he received. As she explained in her letter:
"The Helping Hand Patient Financial Assistance Program offered by Aurora Health Care was a true blessing to my son when an unexpected medical problem was diagnosed. As a full time college student who was participating in the Trade Adjustment Assistance program, my son didn’t have any health insurance.
Along with the intimidating diagnosis came the trepidation and uncertainty regarding the financial impact involved. The most important aspect was treating the medical problem, followed by how to pay for the procedures necessary to treat the problem.
I feel incredibly fortunate to have worked with Jeanne Witkowski. Besides being knowledgeable, Jeanne is compassionate and caring and was always a nurturing presence throughout the entire process. There truly are not enough words to describe how wonderful Jeanne was during this time of stress, and I thank Jeanne and Aurora Health Care for the assistance that was provided."
Respectfully yours, Karen
Karen later wrote to provide an update:
"In addition to the wonderful Aurora Helping Hand Patient Financial Assistance Program news, my son also graduated from the welding course at MATC and was offered a job in Mequon as a CNC operator! My family and I are forever grateful to Aurora Health Care’s generous support."
Aurora St. Luke’s Medical Center, Milwaukee
Submit community benefit stories to Mary Kay Grasmick, editor, at
Read more about hospitals connecting with their communities at www.WiServePoint.org.
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